Factors affecting functional outcome in patients with traumatic brain injury sequelae: Our single-center experiences on brain injury rehabilitation.

OBJECTIVES: This study aims to investigate the effect of rehabilitation on functional level of traumatic brain injury (TBI) patients and to examine the associated factors on functional gain in this patient population. PATIENTS AND METHODS: Between October 2010 and November 2015, a total of 71 patients (63 males, 8 females; mean age 26.6±8.1 years; range, 18 to 56 years) who were admitted to our rehabilitation clinic with moderate-to-severe TBI were retrospectively analyzed. Functional recovery was assessed using the Functional Independence Measure (FIM) and Functional Ambulation Classification (FAC) scales. The patients were divided into two groups according to time from TBI to the initiation of rehabilitation: early (<6 months) and late (≥6 months). Possible predictive factors associated with FIM gain were evaluated. RESULTS: There was a significant improvement in the FIM scores from admission to discharge (p<0.001). There was a statistically significant difference in the FIM gain and FIM efficiency between the patient groups according to the initiation of rehabilitation (p<0.001). The FAC scores increased from admission to discharge, showing statistical significance (p<0.001). Duration of rehabilitation, early rehabilitation, heterotopic ossification, and deep venous thrombosis were found to be significant factors associated with FIM gain (p<0.001). CONCLUSION: Our study results suggest that rehabilitation is effective for functional gain, particularly in the early period in patients with moderate- to-severe TBI and duration of rehabilitation, early rehabilitation, heterotopic ossification, and deep venous thrombosis are also predictors of functional improvement.

Are rehabilitation outcomes after severe anoxic brain injury different from severe traumatic brain injury? A matched case-control study.

Many reports have investigated rehabilitation outcomes after a traumatic brain injury (TBI); however, comparably less is known about whether they differ from outcomes of an anoxic brain injury (ABI). Thus, we aimed to compare the rehabilitation outcomes of patients with ABI with control patients who have TBI. Forty participants with ABI and 40 participants with TBI were included in this retrospective study. Participants with ABI were matched with participants with TBI who had similar clinical characteristics such as age, initial Functional Independence Measurement (FIM) score, and duration of coma. FIM and Functional Ambulation Classification (FAC) scores on rehabilitation admission and on rehabilitation discharge were recorded. The FIM score in the ABI group was 41.7±28.5 on rehabilitation admission and increased to 57.1±31.4 on rehabilitation discharge. The FIM score in the TBI group was 40.8±24.0 on rehabilitation admission and increased to 65.9±35.3 on rehabilitation discharge. There was no statistically significant difference in the FIM scores on rehabilitation discharge between groups. Initial FAC was similar in both groups and there was no statistically significant difference in the FAC scores on rehabilitation discharge. The multiple linear regression analysis showed that intensive care unit length of stay had an inverse relationship with the FAC change. We did not find significant differences in the rehabilitation outcomes of participants with ABI compared with participants with TBI. Considering the lack of information in the literature on ABI rehabilitation, this study may be important to guide rehabilitation teams.

Inter-rater agreement of the Turkish version of the Neurobehavioral Rating Scale-Revised form.

OBJECTIVES: This study aims to adapt the Neurobehavioral Rating Scale-revised form (NBRS-R) for Turkish traumatic brain injury (TBI) patients and to investigate the inter-rater agreement of the Turkish revised scale. PATIENTS AND METHODS: A total of 45 patients (36 males, 9 females; mean age 31.1±13.0 years; range 18 to 60 years) with TBI were included in this study between September 2013 and August 2014. A semi-structured interview was set up for Turkish patients using a multidisciplinary approach (physiatrist, psychiatrist, neurologist and psychologist) with the participation of four rehabilitation centers. Questions were prepared for each of the 29 items, based on the recommendations of the original NBRS-R form. Four different interviewers from the four centers applied this form to a total of 45 TBI patients. RESULTS: The items evaluated by intra-class correlation coefficient showed satisfactory stability and the reliability of the items ranged from moderate to very good. CONCLUSION: The NBRS-R form can be suggested to provide a reliable and easily reproducible evaluation method of neurobehavioral deficits in TBI patients who speak Turkish.

Assessment of forearm muscle spasticity with sonoelastography in patients with stroke.

OBJECTIVE: The aim of the study was to investigate the feasibility of sonoelastography to show muscle stiffness in post-stroke spasticity, and the relationship between sonoelastography findings and clinical spasticity scores in the spastic forearm muscles. METHODS: This study was carried out in a university rehabilitation centre. 23 patients with stroke with forearm muscle spasticity (≥1+ using the Modified Ashworth scale score and ≥1 using the Tardieu scale) were included. Sonoelastography parameters (elasticity index and elasticity ratio) were measured from the flexor digitorum superficialis, flexor digitorum profundus, flexor carpi radialis and flexor carpi ulnaris muscles on the affected and unaffected sides. RESULTS: Both elasticity index and elasticity ratio of the wrist and finger flexors on the hemiplegic side were significantly increased compared with those on the healthy side (p < 0.05). The Tardieu angle of finger flexors was negatively correlated with the elasticity index and elasticity ratio measured in the spastic flexor digitorum profundus (r = -0.418 and r = -0.469, respectively). Tardieu angle of finger flexors was negatively correlated with the elasticity index measured in the spastic flexor digitorum superficialis (r = -0.435). There was no correlation between other parameters. CONCLUSION: Sonoelastography may provide objective assessment of spasticity both in diagnosis and follow-up. To strengthen this prediction, further studies are necessary. Advances in knowledge: The results of this study represent that sonoelastography is a promising evaluation method for forearm muscle spasticity.

Assessment of Spasticity With Sonoelastography Following Stroke: A Feasibility Study.

OBJECTIVE: To investigate the feasibility of sonoelastography to show muscle stiffness in poststroke spasticity, as well as the relationship between sonoelastography findings and muscle architecture features and clinical spasticity scores in the spastic gastrocnemius. DESIGN: Cross-sectional study. SETTING: University rehabilitation center. PARTICIPANTS: A total of 26 stroke patients with gastrocnemius muscle spasticity (≥1 using the Modified Ashworth Scale score). INTERVENTIONS: None. MAIN OUTCOMES: Sonoelastography parameters (elasticity index and elasticity ratio) and muscle architecture features (muscle fascicle length, fascicle pennation angle, muscle thickness and compressibility) were measured from the medial and lateral gastrocnemius muscle on both the affected and unaffected sides. RESULTS: Both the elasticity index and elasticity ratio on the affected side were significantly increased in both the medial and lateral gastrocnemius compared with those on the unaffected side (P < .05). Of the muscle architecture parameters, the compressibility in the medial and lateral gastrocnemius and the fascicle pennation angle in the lateral gastrocnemius were significantly decreased on the affected side (P < .05). There was no significant difference in other parameters between the affected and unaffected side (P > .05). Sonoelastographic findings showed a weak negative correlation with compressibility and a weak positive correlation with the Modified Ashworth Scale score in the spastic medial gastrocnemius. CONCLUSIONS: It was found to be feasible to assess stiffness in spastic gastrocnemius muscles of stroke patients with sonoelastography. Further studies are needed to confirm the potential role of sonoelastography to help guide treatment of spasticity and its sequelae.

Botulinum toxin injection for bruxism associated with brain injury: case report.

Bruxism is involuntary grinding of the teeth and can occur as a complication of brain injury. If untreated, bruxism can lead to severe occlusal trauma. Herein, we present a patient with traumatic brain injury and nocturnal bruxism that was treated with botulinum toxin injection. A 21 yr old male patient with traumatic brain injury from a car accident was admitted to our inpatient rehabilitation unit. He had a history of coma for 2 wk in the intensive care unit. The initial cranial computed tomography scan indicated a superior thalamic hemorrhage. On admission to our department 3 mo postinjury, his mental status was good and he was able to walk without assistance, but he had mild ataxia. He complained about severe teeth grinding at night, which began 2 mo postinjury. Botulinum toxin-A was injected into the masseter muscles (20 U in each muscle) and temporalis muscles (15 U in each muscle) bilaterally. A decrease in bruxism was reported within 3 d. Clinical improvement persisted at assessment 4 mo posttreatment. Botulinum toxin injection can be used as an effective treatment for bruxism associated with brain injury.

Effects of botulinum toxin-A on the muscle architecture of stroke patients: the first ultrasonographic study.

OBJECTIVE: The aim of this study was to explore in vivo the effects of botulinum toxin-A treatment on the muscle architecture of patients with stroke, using musculoskeletal ultrasonography. METHODS: This prospective clinical trial included 26 adult stroke sufferers with a mean age of 55 years (standard deviation 14). Pennation angles between the fascicle path and the deep aponeurosis of the muscle, fascicle length, muscle thickness and muscle compressibility were scanned at the bulkiest part of the medial gastrocnemius on both limbs. Sonographic evaluations were performed initially before botulinum toxin-A injection and repeated on day 10 and after 2 months. RESULTS: On the hemiplegic sides, anterior pennation angle and muscle thickness decreased (p = 0.014, p = 0.010, respectively), fascicle length increased (p = 0.025) and muscle compressibility did not change after 2 months of treatment compared with the baseline values. CONCLUSION: The results confirm that muscle structure changes due to botulinum toxin-A. Long-term effects of botulinum toxin-A, timing for disappearance of the toxin effects, or evaluations for repeat injections, remain to be studied. The use of musculoskeletal ultrasonography appears to be promising in this regard. :

Early rehabilitation outcome in patients with middle cerebral artery stroke.

Although important data on the prognosis and rehabilitation outcome in stroke patients have been reported, data on functional recovery according to stroke subtypes are limited. This retrospective study aimed to evaluate functional outcome in patients with middle cerebral artery (MCA) stroke-the most common subtype of ischemic stroke. The records of stroke patients that underwent the rehabilitation program at our brain injury rehabilitation service between January 2007 and December 2008 were reviewed, and those with MCA stroke were included in the study. Patient demographic and clinical data, and Barthel Index (BI) and Functional Independence Measure (FIM) scores at admission and discharge were collected. The study included 80 MCA stroke patients with a mean age of 63.54 years. FIM and BI scores improved significantly post rehabilitation (P<0.05). Age was negatively correlated with both BI and FIM scores at admission and discharge. Length of stay was not correlated with improvement in BI or FIM scores during hospitalization. The patients that had ≤1 month of inpatient rehabilitation had similar outcomes as those that had >1 month of inpatient rehabilitation (P>0.05). Length of time after stroke onset was not correlated with BI or FIM scores at admission. Regardless of initial functional status, prediction of discharge functional status was misleading. Physiatrists should keep in mind that functional improvement does not always increase with duration of inpatient therapy.

Severe heterotopic ossification in the non-affected limbs of a hemiplegic patient with traumatic brain injury.

BACKGROUND/OBJECTIVE: Heterotopic ossification characterized by new bone formation in the periarticular regions of large joints in patients with neurologic injury most commonly occurs on the neurologically involved side. This study presents a very rare localization of heterotopic ossification that developed in the non-paretic limbs of a hemiplegic patient with traumatic brain injury (TBI). CASE REPORT: A 25-year-old left hemiplegic male with TBI due to a gunshot wound was admitted to the rehabilitation centre after a 2.5-month period of coma in the intensive care unit. He had limited range of motion accompanied by pain in the bilateral hip, bilateral elbow and right knee joints. Neurological examination revealed upper motor neuron lesions only on the left side in neurological exam. Plain radiographs of the involved joints revealed bilateral heterotopic ossification, which was more severe on the non-paretic side. DISCUSSION: Clinicians should keep in mind that heterotopic ossification can occur in non-hemiplegic extremities as well as hemiplegic extremities in patients with TBI in whom the extent of neurologic damage cannot be definitely established.

Which treatment approach is better for hemiplegic shoulder pain in stroke patients: intra-articular steroid or suprascapular nerve block? A randomized controlled trial.

OBJECTIVE: To determine which injection technique was effective for patients with hemiplegic shoulder pain. DESIGN: Randomized prospective double-blind study. SETTING: Brain Injury Rehabilitation Unit. INTERVENTION: Patients with hemiplegic shoulder pain were recruited over a 12-month period and all were hospitalized in our clinic. Intra-articular steroid injection or suprascapular nerve block was performed on all patients. MAIN MEASURES: Range of motion values at the moment that pain started (range of motion A) and passive maximum range of motion values (range of motion B) were recorded. Pain intensity levels (visual analogue scale) at these two range of motion values (pain A and pain B) were also taken. Evaluations were made before the injection, and 1 hour, one week and one month after the injection. RESULTS: Twenty-six patients were enrolled in the study, the mean age was 61.53 ± 10.30 years. The mean time since injury was 8.69 ± 15.71 months. The aetiology was ischaemic in 16 (61%) patients. Intra-articular steroid injection was performed in 11 (42 %) patients, and suprascapular nerve block in 15 (57%) patients. Range of motion A and range of motion B were changed statistically in repeated measures. There were important differences in repeated measures of pain intensity levels at these two range of motion values (P < 0.05). However, no significant differences were determined in all measurements between intra-articular steroid injection and suprascapular nerve block groups (P > 0.05). CONCLUSIONS: Our results showed that neither injection technique was superior to the other. Both injection procedures are safe and have a similar effect in stroke patients with hemiplegic shoulder pain.

Epidemiologic data of the patients with spinal cord injury: seven years' experience of a single center.

BACKGROUND: We aimed to present the demographic and epidemiologic data on spinal cord injury (SCI) patients who were rehabilitated at our hospital, to identify high-risk groups and etiological factors, and to evaluate the factors that affect the duration of hospitalization (DOH). METHODS: Data on 905 SCI patients treated on an inpatient basis between December 2000 and June 2007 at our hospital were retrospectively evaluated. Patient age, sex, etiology of injury, DOH, neurologic level, and functional grouping were analyzed. Additionally, the effects of age and sex on DOH were evaluated. RESULTS: In total, 661 (73%) of the patients were male and 244 (27%) were female. The mean age of the patients was 33.4±15.0 years; 51.27% of the patients were 20-33 years of age. The mean DOH was 73.6±49.8 days. In all, 304 (33.5%) of the patients were tetraplegic and 601 (66.5%) were paraplegic. Motor vehicle collisions were the most common cause of injury (n=318, 35.1%), followed by falls from an elevated height (n=170, 18.8%). DOH was significantly higher among the tetraplegia American Spinal Injury Association (ASIA) A-B patients than among the other patients (p<0.01). CONCLUSION. It is clear that most of the SCIs we observed were preventable. Comprehensive identification of the epidemiologic, demographic and pathologic features of SCIs contributes to identifying high-risk groups, thereby making it possible to pay personal and communal attention to precautions for SCIs.

Effect of autonomic dysfunction on p-wave dispersion in patients with chronic spinal cord injury.

OBJECTIVE: To provide information about the effect of autonomic dysfunction on P-wave dispersion, as a predictor of atrial fibrillation, in patients with spinal cord injury. DESIGN: Thirty patients with chronic traumatic spinal cord injury and 27 healthy controls were included in this study. The initial assessment of the patients included routine physical examination and evaluation of 12-lead electrocardiography. In the patient group, blood pressure and electrocardiography recordings were obtained during urodynamic assessment. The measurements of the P-wave duration were performed manually by two blinded investigators. P-wave dispersion was calculated as the difference between maximum P-wave duration and minimum P-wave duration. P-wave dispersion values of resting electrocardiography recordings in control and study groups were compared. In the patient group, subgroup analyses were also performed according to the injury level and severity and existence of autonomic dysfunction in examinations. RESULTS: P-wave dispersion values were greater in patients with spinal cord injury than in healthy controls. There was statistically significant difference between P-wave dispersion values of the patients with and without autonomic dysfunction. P-wave dispersion values at initial sensation of vesical filling were greater than those of the resting state in the patients without autonomic dysfunction. CONCLUSIONS: Our findings indicate that P-wave dispersion increases significantly in chronic spinal cord injured patients with autonomic dysfunction. This finding suggests a tendency for atrial fibrillation occurrence in patients with spinal cord injury, which may cause further cerebrovascular complications in this special subset of patients by creating a thromboembolic milieu.

Short-term exercise approaches on menopausal symptoms, psychological health, and quality of life in postmenopausal women.

Objective. This study was designed to determine the effects of different short-term exercise programs on menopausal symptoms, psychological health, and quality of life in postmenopausal women. Material and Methods. Forty-two women were chosen from volunteering postmenopausal women presenting to the Department of Obstetrics and Gynecology of Bayindir Hospital between March and December 2009. The women aged 45-60 years and experiencing menopause naturally were included in the study. They were randomly divided into aerobic (n = 18) and resistance (n = 18) exercise groups. The women exercised 3 days per week for 8 weeks under the supervision of a physiotherapist. Aerobic exercise training was performed through a bicycle ergometer. Before and after the training, lipid profiles were measured and menopausal symptoms, psychological health, depression, and the quality of life were assessed through questionnaires. Results. In both exercise groups, no significant changes in lipid profiles were observed. In the resistance exercise group, excluding the urogenital complaints, there were significant improvements in all subscales of Menopausal Rating Scale (MRS). In the resistance exercise group, excluding the phobic anxiety, there were significant improvements in all subscales of The Symptom Checklist. Depression levels significantly decreased in both groups. Improvements were observed in all subscales of menopause-specific quality of life questionnaire in both groups except for sexual symptoms. Conclusion. Resistance exercise and aerobic exercise were found to have a positive impact on menopausal symptoms, psychological health, depression, and quality of life.

Autonomic dysreflexia as a complication of a fecal management system in a man with tetraplegia.

BACKGROUND/OBJECTIVE: To present a case of autonomic dysreflexia caused by the use of a fecal management system in a patient with tetraplegia. DESIGN: Case report. SETTING: Military rehabilitation center. RESULTS: A man with tetraplegia had a fecal management system inserted to divert stool away from his sacral pressure ulcer to reduce contamination and infection risk. Two days later, he developed severe autonomic dysreflexia that improved after removal of the system. CONCLUSIONS: Autonomic dysreflexia, a life-threatening complication, has not been reported before as a side effect of a fecal management system. These systems should be used with caution in patients with high-level spinal cord injury.

The efficacy of serial casting after botulinum toxin type A injection in improving equinovarus deformity in patients with chronic stroke.

INTRODUCTION: Spasticity is an important early complication of stroke, which may lead to shortening of gastrocnemius and soleus muscles and contracture in the Achilles tendon and soft tissues of the ankle. Botulinum toxin A (BTX-A) is a promising drug for the management of focal spasticity. Serial casting is another alternative method for reducing contractures due to spasticity. The present study aimed to determine if serial casting after BTX-A injection could help to limit the development of calf contracture in chronic hemiplegic patients. METHOD: The records of patients with stroke that were treated in the brain injury rehabilitation clinic between January 2007 and December 2008 were screened. In all, 10 patients that underwent a serial casting programme for 24 days following BTX-A injection were included in the study. Goniometric scores for ankle ROM, Physician Rating Scale (PRS) and Functional Independence Measurement (FIM) scores were recorded. RESULTS: Mean age of the patients was 33.2 years. Mean time interval after stroke onset was 35.0 months. Improvements in ROM were quite significant after serial casting. Moreover, FIM and PRS scores improved significantly. CONCLUSION: Serial casting may be an appropriate intervention following BTX-A injection to prevent equinovarus deformity and improve the quality of walking in chronic stroke patients. The role of casting and splinting are important topics that require further research.

Medical complications, physical function and communication skills in patients with traumatic brain injury: a single centre 5-year experience.

OBJECTIVE: The aim of this retrospective study was to review the medical complications of patients with traumatic brain injury (TBI) who were followed in 2000-2006. METHODS AND PROCEDURES: The demographic data, functional and cognitive status of 116 persons with TBI were noted. The presence of communication problems, swallowing disturbances, urinary and faecal incontinence, pressure ulcer, deep venous thrombosis (DVT), post-traumatic seizure (PTS) and heterotopic ossification (HO) were recorded at first admission and follow-up. MAIN OUTCOME AND RESULTS: This study detected aphasia in 19.0%, dysarthria in 30.2%, dysphagia in 17.2%, pressure ulcers in 6.9% and DVT in 2.6% the our patients with TBI. Urinary and faecal incontinence on admission were 32.7% and 26.7%, respectively. Patients with incontinence had poorer cognitive function than those with normal continence. HO rate was 18.1% and the ambulation levels of patients with HO were worse than those without HO. PTS was seen in 13.8% of the patients on admission and this ratio increased to 21.6% during the follow-up. In these patients, the aetiological risk factors for PTS were gunshot and fall injuries. CONCLUSIONS: Considering the wide spectrum of complications, this study advocates that these persons with TBI should be followed promptly by a multidisciplinary team.

Does standing protect bone density in patients with chronic spinal cord injury?

BACKGROUND/OBJECTIVE: To compare the t-scores of proximal femur and lumbar spine of patients with spinal cord injury (SCI) with different levels of weight bearing. METHODS: Cross-sectional study comparing 3 groups of patients with SCI: patients with daily standing times of more than 1 hour, patients with daily standing times of less than 1 hour, and nonstanding patients. Seventy-one patients with chronic SCI were recruited. They were assigned to 1 of 3 groups according to their reported daily standing time. The bone density of lumbar and proximal femoral regions was measured with dual-energy x-ray absorptiometry. RESULTS: The 3 groups were similar in terms of demographics and clinical variables. No significant difference was found among the mean t-scores of lumbar and proximal femoral regions of the groups. However, the patients in the group that stood more than 1 hour daily had a slight tendency to have higher t-scores than those in the control group. CONCLUSIONS: There was no significant difference among the 3 groups. However, standing might be partially helpful in protecting the bone density in SCI by opposing the effects of immobilization.

A heterotopic ossification related to temporary placement of a skull bone flap. Case report.

The authors report on a 19-year-old man who sustained a traumatic brain injury. Following decompressive craniotomy, he suffered from an unusual heterotopic ossification due to the temporary placement of the skull bone flap in his thigh. To the best of the authors' knowledge, this is the first time that a possible causal relationship between these entities has been reported in the literature.